What are disease modifying antirheumatic drugs (DMARDs)?

Disease modifying antirheumatic drugs (DMARDs) are a group of medicines used to treat rheumatoid arthritis (RA) as well as some other conditions, such as psoriatic arthritis, ankylosing spondylitis and juvenile arthritis. They are the preferred treatment for RA, and you may take one medicine or a few types of medicines. DMARDs stop or slow the disease process in inflammatory forms of arthritis and helps to preserve joints.

How do DMARDs work?

Many DMARDs reduce your body’s immune system response — this is called immunosuppression. This is helpful because RA is an autoimmune condition where your immune system damages your joints. This immunosuppression can help reduce inflammation and damage to your joints which may occur in RA. It is important to start taking DMARDs as soon as possible after your doctor diagnoses RA.

All DMARDs are prescription medicines and are usually prescribed by a specialist doctor, such as your rheumatologist. They come in different forms including:

• tablets
• injections that you inject yourself at home
• infusions that are given by nurse into a vein, usually in a clinic

Different DMARD medicines are taken at different times. You need to take some daily, such as hydroxychloroquine. You will take some DMARD medicines like methotrexate, once a week but you take others like infliximab every 6 weeks, or even less often. Talk to your pharmacist to make sure you know how and when to take your medication.

Conventional DMARD medicines such as methotrexate may take several weeks before they work optimally. Your doctor may prescribe other medicines to help manage pain and inflammation such as NSAIDs.

What types of DMARDs might I be given or prescribed?

There are 3 main classes of DMARDS:

1. Conventional synthetic DMARDs, including medicines such as methotrexate, corticosteroids, sulfasalazine, hydroxychloroquine and leflunomide.
2. Targeted synthetic DMARDs, including JAK inhibitors, tofacitinib, baricitinib and upadacitinib.
3. Biological DMARDs, including infliximab, etanercept, adalimumab (known as TNF inhibitors), anakinra, tocilizumab, rituximab, and abatacept.

Biological DMARDs are usually prescribed if other DMARDs have not been effective.

Your doctor will prescribe a DMARD for you based on:

• how long you have had RA
• what treatments you have tried already
• how severe your condition is
• if you have other medical conditions

They will also consider your preferences and personal needs, such as if you are planning a family soon, and if the cost of medicines is a concern for you.

Do DMARDs have any side effects or risks associated with it?

Every medicine, including DMARDs has risks, side effects and benefits. You should speak with your doctor about how you can balance the risks and benefits of your medicines, according to your own circumstances.

Side effects of DMARDs

Methotrexate (a type of conventional synthetic DMARD) causes side effects such as stomach pain, liver problems and hair loss. Ask your doctor about taking a folic acid supplement to lower your risk of liver problems or stomach pain.

If you experience side effects, talk to your doctor, so they can review your medicines and dosage.

Find out more about the DMARDs you are taking, including side effects.

Risks of DMARDs

DMARDs affect your body’s immune system response. People with RA are more likely to catch infections compared to people who don’t have RA. The risk is higher if you take corticosteroids or more than one DMARD, especially if one is a biological DMARD. If you have an infection, you may not get fevers as you normally would, because of how the medicines affect your immune system.

You are also at higher risk of getting skin cancers when taking DMARDs. Sun protection and skin cancer screening is especially important.

If you have had a previous tuberculosis infection, starting DMARDs can reactivate it. Your doctor will make sure that you have a screening to check for tuberculosis before you start the DMARD.

When you are taking DMARDs, it is important to have other regular vaccinations, such as for pneumococcus, influenza, hepatitis and human papillomavirus, but you should not have live vaccines (vaccines containing live viruses or bacteria that are weakened (‘attenuated’)). Ask your doctor for advice on which vaccines you need and when to have them.

When should I see my doctor?

Your doctor will tell you when you can expect your symptoms to improve. See your doctor if your symptoms aren’t improving as expected, or if they get worse.

You should also see your doctor if you have any side effects.

It is important to see a doctor quickly if you think you may have signs of an infection. Your symptoms may not be severe, and you may not have a fever, but treating the infection is important because your immune system is affected by DMARDs.

Are there any alternatives to this medicine?

There are many DMARDs available. If one doesn’t work for you, or you have side effects, your doctor may prescribe a different one, or add another medicine.

There are medicines that can help you with your pain, but they don’t treat the cause of the inflammation or stop joint damage. These include non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol.

There is no evidence that complementary medicines have any benefit.

You can use self-management techniques to help your RA symptoms, together with DMARDs. You can try heat or cold packs on sore joints and relaxation techniques for pain.

It is important you stop smoking, do regular exercise, eat a healthy diet and look after your mental health. Omega-3 fatty acids can improve pain and reduce your need for pain medicines. A physiotherapist or occupational therapist can give you advice on how to manage your symptoms.

Resources and support

To better understand the path you may follow from diagnosis to treatment, check out the NPS Medicinewise roadmap for rheumatoid arthritis. To better understand the path you may follow from diagnosis to treatment, check out the NPS Medicinewise roadmap for rheumatoid arthritis.

The Australian Rheumatology Association has information sheets about each DMARD and other medicines used to treat RA.

The Arthritis Australia MyRA Rheumatoid Arthritis Support Program includes videos and fact sheets on DMARDs. Arthritis Australia has information sheets about rheumatoid arthritis in different languages.